Community Home Health Care

The home health agency failed to ensure the EP Communication Plan included the physician’s name and contact information for each patient for 1 of 1 agency.

The home health agency failed to ensure initial EP policy and procedure training was completed at hire by all employees for 2 of 6 employee inservice records reviewed (Employee E, F).

The home health agency failed to document the agency’s response following actual emergency events for 1 of 1 agency.

The agency failed to ensure the POC included medication orders that included the route, dose, frequency, and included the location of application for 2 of 5 active records reviewed (Patient #3, 5) and for 1 of 2 discharged records reviewed (Patient #6).

The RN failed to ensure the ongoing interdisciplinary assessment included the staging of wounds for 1 of 3 active records reviewed of patients with wounds (Patient #2) and failed to include a pain assessment for 1 of 4 active records reviewed of patients taking scheduled pain medications (Patient…

The SN failed to ensure orders were obtained for all services provided for 1 of 3 active records reviewed of patients with wounds (Patient #2).

The agency failed to ensure the HHA provided services included in the HHA POC and provided services consistent with home health aide training for 1 of 1 home visit observations of HHA providing care (Patient 3).

The agency failed to ensure policies and procedures implemented all elements of the COVID-19 vaccination mandate and failed to ensure 100% of their 88 active employees, completed the COVID-19 vaccine series, was granted a qualifying exemption, or received a temporary delay for 1 of 1 agency…

The agency failed to ensure home health aide (HHA) care plans were appropriate and specific to the needs of the patient for 2 of 3 records reviewed with HHA services (Patients #2 and 3).

The agency failed to ensure all patients’ plans of care included the required elements of as safety precautions, functional limitations, and medications for 2 of 3 plans of care reviewed (Patients #1 and 3).

The agency failed to ensure the plan of care was updated to contain all physician orders in 1 of 3 records reviewed (Patient #1).

The agency failed to ensure home health aides (HHA) do not practice out of the scope of practice in regard to the administration of prescribed medications for 1 of 3 records reviewed with HHA services (Patient #3).

The agency failed to ensure patients are accepted for treatment on the reasonable expectation that they can meet the needs of patients (See G570); failed to ensure home health aide visits were provided as ordered by the physician on the plan of care and not reduced due to the agency's inability to…

The agency failed to ensure home health aide (HHA) care plans were appropriate and specific to the needs of the patient (See G798); the agency failed to ensure that home health aides do not practice out of their scope of practice in regards to determining if a patient has an injury after a fall…

The registered nurse failed to update the comprehensive assessment when a patient had a change in condition following a fall for 1 of 7 incident reports reviewed (Patient #6).

The agency failed to ensure home health aide visits were provided as ordered by the physician on the plan of care and not reduced due to the agency's inability to staff in 4 of 7 Patients (#1, 3, 5, 7).

The Governing Body failed to ensure their policy did not put the patient or patient representative responsible for providing care and failed to ensure their policy included a plan to ensure no patient went without services when the agency’s designated employee(s) was not available.

The agency failed to ensure the safety of 4 of 4 patients (Patients #6, 9, 10, 12) and failed to ensure 2 of 2 patients (Patients #6 and 9) were free of injury when care was provided in 5 of 5 incidents reviewed involving one home health aide (Employee B) during a period of May 2021 to November…

The agency failed to document the resolution of complaints for 3 of 6 complaints reviewed (Patients #15, 17, 18, 19, 20, and 21).

The registered nurse failed to assess patients when notified of falls for 4 of 7 incident reports reviewed (Patients #6,11,12) Findings include: 1. Review of an agency policy dated 6/2015, titled “Policy 2.002 Client Accident/ Incident” indicated “… all client accidents/ incidents are reported as…

The home health aides failed to ensure they notifed the registered nurse and/ or clinical manager of patient falls immediately per agency policy for 5 of 7 incident reports reviewed (Patients #6, 8, 9,10,12).

The Supervising Nurse failed to ensure made on an on-site visit to ensure competency of a home health aide (Employee B) involved in 5 incidents between May 2021 to November 21, in which 2 of the 5 incidents resulted in patient injury (Patient #6, 9,10,12).

The home health agency failed to ensure employees adhered to agency infection control policies for 2 of 2 home visit observations (#1, 2).

The home health agency failed to develop and maintain an agency-wide program for the surveillance, control, prevention, and investigation of infectious and communicable diseases, specifically COVID-19, among its employee and patients, which had the potential to effect 3 patients (#4, 5, 6) and 3…

The home health agency failed to ensure all staff were educated on CDC recommendations in relation to the COVID-19 pandemic, and failed to implement infection control policies that adhered to recognized national standards and recommendations by the CDC.

The home health agency failed to document the existence, investigation, and resolution of patient complaints for 1 of 4 records reviewed (#3).

The agency failed to fully review and update the Emergency Preparedness Plan (EPP).

The agency failed to ensure all visits were made as ordered on the plan of care for 1 of 9 clinical records reviewed (# 1) and failed to ensure skilled nursing frequency was clarified and specific to the patient's needs for 1 of 9 clinical records reviewed.

The agency failed to ensure staff followed infection control policies and procedures for 2 of 3 home visits.

The agency failed to ensure the home health aide (HHA) followed the aide care plan for 1 of 1 HHA observation.

The agency failed to ensure the skilled nurse (SN) completed drug regimen reviews at appropriate times for 1 of 9 clinical records reviewed (#2).

The governing body failed to ensure the appointments of the administrator, the alternate administrator, the nursing supervisor, and the alternate nursing supervisor.

The agency failed to report a branch office to the Indiana State Department of Health (ISDH).